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F0585
E

Failure to Provide Anonymous Access to Grievance Forms

Elkhart, Indiana Survey Completed on 02-24-2026

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor residents’ right to file grievances anonymously by not making grievance forms readily and independently accessible to residents. During a Resident Council meeting, all 12 residents present reported that grievance forms were kept behind the nursing station and that they had to ask staff to obtain a form, which prevented them from submitting grievances anonymously. In a subsequent observation and interview, the Executive Director confirmed that grievance forms were located behind the nurse’s station and were not available for residents to access without staff assistance, and also noted that there were no forms present in the plastic wall hanger behind the nurse’s station at that time. This practice conflicted with the facility’s written “Resident Concerns and Grievances” policy, which states that residents, representatives, and family members have the right to file grievances orally or in writing, to file grievances anonymously, and that grievances can be submitted anonymously with anonymity maintained by the Grievance Official throughout the resolution process. As a result, for all 65 residents in the facility, grievance forms were not readily available in a manner that allowed anonymous submission, and residents were required to request forms from staff, contrary to the facility’s stated policy and residents’ rights to file grievances without fear of reprisal or discrimination.

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